Monday, March 19, 2018

Washington, DC, USA

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Fertility Preservation in Women

Review Article New England Jornal of Medicine Report

Fertility Preservation in Women J. Donnez and M.-M. Dolmans

CME Exam

Of all the available means of fertility preservation, oocyte cryopreservation by means of vitrification (very rapid freezing) provides the highest yield, not only for women with benign diseases or those seeking fertility preservation for personal reasons but also for women with cancer. Ovarian-tissue cryopreservation is specifically indicated for adolescents and women in whom cancer treatment cannot be postponed.

Clinical PearlsClinical Pearl What nononcologic conditions may be associated with premature ovarian insufficiency?Fertility preservation should be offered to women with certain benign conditions that carry the risk of premature ovarian insufficiency. Many autoimmune and hematologic conditions sometimes require chemotherapy, radiotherapy, or both and sometimes even bone marrow transplantation. Other conditions can also impair future fertility, such as the presence of bilateral ovarian tumors, severe or recurrent ovarian endometriosis, and recurrent ovarian torsion.

Clinical Pearl What is the preferred method for oocyte cryopreservation?Data from a recent review suggest that the strategy of oocyte vitrification and warming is superior to slow freezing and thawing in terms of clinical outcomes. On the basis of this evidence, laboratories that continue to use slow freezing should consider transitioning to vitrification techniques for purposes of cryopreservation.

Morning Report QuestionsQ. How important is the age of the patient when oocyte vitrification is undertaken? A. Cobo et al. recently reported outcomes for 137 women who had undergone fertility preservation by means of oocyte vitrification for nononcologic reasons and subsequently returned to use their oocytes. A total of 120 women had undergone the procedure to circumvent age-related fertility decline. Among women who were 35 years of age or younger at the time of oocyte vitrification, the cumulative live-birth rate was much lower when only 5 oocytes were used (15.4%) than when 8 or 10 oocytes were used (40.8% and 60.5%, respectively). Among women who were older than 35 years of age at the time of the procedure, the cumulative live-birth rates were 5.1%, 19.9%, and 29.7% with 5, 8, and 10 oocytes, respectively. Hence, with 10 oocytes, the cumulative live-birth rate was twice as high in the group of women who were 35 years of age or younger (60.5%) as in the group of older women (29.7%).

Q. How is ovarian-tissue cryopreservation accomplished? A. Ovarian tissue is removed in the form of multiple biopsy specimens (or an entire organ) and cut into cortical strips. The tissue is then cryopreserved by slow freezing on site (or transported to a processing site at a temperature of 4°C). After thawing, if there is no risk of transmitting malignant cells, the ovarian tissue can be grafted to the ovarian medulla (if at least one ovary is still present) or reimplanted inside a specially created peritoneal window. After reimplantation of ovarian tissue in the pelvic cavity, ovarian activity is restored in more than 95% of cases. The mean duration of ovarian function after reimplantation is 4 to 5 years, but the function can persist for up to 7 years, depending on the follicular density at the time of ovarian-tissue cryopreservation. The first pregnancy after this procedure was reported in 2004. The number of live births as of June 2017 exceeded 130. Transplanting ovarian tissue to heterotopic sites remains somewhat questionable, however, and only one pregnancy has been reported in a woman who underwent this procedure.

Figure 1. Options for Fertility Preservation.

How Healthcare Providers Can Maximize Success in a Recruitment Services

Tips That Can Help

Partnership

Success in a recruitment services partnershipA major shortage of healthcare workers, coupled with growing demand for patient care services, has placed healthcare providers in one of the most competitive hiring markets in our nation’s history.

Faced with this challenge, many have sought the expertise of Recruitment Services experts. A quality provider of Recruitment Services, sometimes known as RPO, can deliver a robust candidate database, advanced sourcing techniques, best practice recommendations, clinical experience, benchmarking, and management know-how to help today’s healthcare providers succeed in hiring the best talent in the most cost-effective, efficient and timely manner.

But what can the healthcare provider do to best position themselves for success in working with a Recruitment Services team? The following are tips for getting more out of your partnership:

Communicate Your Goals to Internal Staff

One of the areas that often gets overlooked in initiating a Recruitment Services partnership is ensuring consistent and proactive communication with internal team members, including talent acquisition staff, hiring managers and executives. To ensure their comfort and buy-in to the process, your staff needs to understand why you are looking to a Recruitment Services provider, what the program is going to entail, how it is going to benefit them, and what are the desired outcomes. Ensuring everyone is on the same page – creating a sense of “team” -- will go a long way to achieving a good working relationship and a high level of program success.

Onboard the Recruitment Services Team

Just as you provide orientation for a new recruiter, your staff needs to be available to onboard the Recruitment Services team. This means providing training materials, introduction to systems, access to hiring managers and education, particularly about your organization’s culture. The Recruitment Services team needs to understand your employee value propositions, the selling points of your health system, your career development opportunities, and the community.

Define Roles and Responsibilities

Agreeing up front who is responsible for what part of the process is an important part of successfully integrating the Recruitment Services provider with your team. Delineating the Recruitment Services roles from internal staff roles can help avoid mix ups. This may involve such things as the type of requisitions and departments to be supported by the Recruitment Services team and how they’re going to carry out these functions. Internal staff should understand that the Recruitment Services team is truly an extension of the internal team brought in to supplement the efforts of existing talent acquisition functions.

Select a True Strategic Partner

In addition to aiding your recruitment and hiring, a quality Recruitment Services provider should serve in a consultative role and act as your organization’s strategic long-term partner. This means offering ways to improve your employment brand, working to expand your internal candidate database and recommending process improvements to your systems and recruiting processes. As experts in the field, a quality provider will bring an industry-wide view, with extensive knowledge of best practices and strategies that can be statistically compared with your data. This can provide valuable insights that lead to more cost-effective and efficient strategic decisions.

Agree Upon an Escalation Path and Other Management Issues

With every type of recruiting, occasional challenges will arise. Having a predefined escalation path is key. For example, you and your Recruitment Services partner should agree up front on a structure for resolving hiring issues. A quality Recruitment Services company will recommend a management system customized to your specific needs. For instance, a management system may include a scheduled meeting cadence that says every week both parties will meet to review data or every month you will gather to go over strategy. It can also spell out a report structure with dates for delivering significant information to your organization. Service level agreements that track quarterly performance against agreed upon targets can also be part of this structure.

Targeted Therapy For Ovarian Cancer

Latest Treatment That Damage Cancer Cells

Targeted therapy is a newer type of cancer treatment that uses drugs or other substances to identify and attack cancer cells while doing little damage to normal cells. These therapies attack the cancer cells' inner workings − the programming that makes them different from normal, healthy cells. Each type of targeted therapy works differently, but all alter the way a cancer cell grows, divides, repairs itself, or interacts with other cells.

Bevacizumab (Avastin) belongs to a class of drugs known as angiogenesis inhibitors. In order for cancers to grow and spread, they need new blood vessels to form to nourish the tumors (called angiogenesis). This drug binds to a substance called VEGF that signals new blood vessels to form. This can slow or stop the growth of cancers.

In studies, bevacizumab has been shown to shrink or slow the growth of advanced epithelial ovarian cancers. Trials to see if bevacizumab works even better when given along with chemotherapy have shown good results in terms of shrinking (or stopping the growth of) tumors. But it doesn’t seem to help women live longer.

This drug is given as an infusion into the vein (IV) every 2 to 3 weeks.

Common side effects include high blood pressure, tiredness, bleeding, low white blood cell counts, headaches, mouth sores, loss of appetite, and diarrhea. Rare but possibly serious side effects include blood clots, severe bleeding, slow wound healing, holes forming in the colon (called perforations), and the formation of abnormal connections between the bowel and the skin or bladder (fistulas). If a perforation or fistula occurs it can lead to severe infection and may require surgery to correct.

PARP inhibitors

Olaparib (Lynparza), rucaparib (Rubraca), and niraparib (Zejula) are drugs known as a PARP (poly(ADP)-ribose polymerase) inhibitors. PARP enzymes are normally involved in one pathway to help repair damaged DNA inside cells. The BRCA genes (BRCA1 and BRCA2) are also normally involved in a different pathway of DNA repair, and mutations in those genes can block that pathway. By blocking the PARP pathway, these drugs make it very hard for tumor cells with a mutated BRCA gene to repair damaged DNA, which often leads to the death of these cells.

Olaparib (Lynparza) and rucaparib (Rubraca) are used to treat advanced ovarian cancer, typically after chemotherapy has been tried. These drugs are used mainly in patients who have mutations in one of the BRCA genes. Only a small portion of women with ovarian cancer have mutated BRCA genes. If you are not known to have a BRCA mutation, your doctor will test your blood to be sure you have one before starting treatment with one of these drugs.

Olaparib can also be used to treat patients (with or without a BRCA mutation) with advanced ovarian cancer that has come back after treatment, and then shrank in response to chemotherapy containing cisplatin or carboplatin. Olaparib can help extend the time before the cancer comes back or starts growing again.

In studies, these drugs have been shown to help shrink or slow the growth of some advanced ovarian cancers for a time. So far, though, it's not clear if they can help women live longer.

Niraparib (Zejula) is typically used to treat recurrent ovarian cancer, after chemotherapy has been tried. This drug can be used to treat women with or without a BRCA gene mutation.

All of these drugs are taken daily by mouth, as pills.

Side effects of these drugs can include nausea, vomiting, diarrhea, fatigue, loss of appetite, taste changes, low red blood cell counts (anemia), belly pain, and muscle and joint pain. Rarely, some patients treated with these drugs have developed a blood cancer, such as myelodysplastic syndrome or acute myeloid leukemia.

Other targeted therapy drugs are also being studied.

See Targeted Therapy for more information about these kinds of drugs.Written by Editorial Team of American Cancer SocietyReferences American Cancer Society at Cancer.org

The American Cancer Society medical and editorial content team

OLYMPIC FIGURE SKATING: THE MOST COMMON INJURIES

BEHIND THE ARTISTIC ATHLETICISM:

OLYMPIC FIGURE SKATING: THE MOST COMMON INJURIES BEHIND THE ARTISTIC ATHLETICISM:

With the Winter Olympics well under way, millions of people are yet again drawn to the visual spectacle that is figuring skating. Figure skaters mesmerize us with their effortless elegance and artistic precision as they glide across the ice.

Conveying the perfect balance of artistic expression and dynamic aerial maneuvers, figure skating encompasses a skill set that is unlike any other sport. With most figure skaters reaching their peak between the ages of 16 and 20, mastering the art of figure skating requires an unprecedented determination and discipline at a very young age, as well as a large financial and physical support team. In an article by Huffington Post, Scott Hamilton, former US Olympic Gold medalist, says training to be an Olympic figure skater can cost as much as $25,000-$80,000 when you add up choreographers, costumes, ice time, trainers, and coaches.

US Olympic skaters such as Gracie Gold and Jason Brown have most likely had skates on from the second they can stand, and spend an average of 5-7 hours devoted to on and off-ice training. With 15+ years of intense training, figure skaters are no stranger to injury, and have their share of “sports-specific problems”. A recent article in Current Sports Medicine Reports, discusses the most common injuries behind these artistic athletes.

As you would imagine, with all of that time in ice skates, the feet and ankles are prime targets for injuries in skaters. The stiff leather boots and rigid blades, can cause conditions such as “Lace Bite”, which is irritation of the muscle tendons that cross the ankle joint underneath the laces, and “Pump Bump”, where the outside of the heel grows outward, caused by repeated friction from an improperly sized skate. Stress fractures of the foot bones are also extremely common, because of the excessive force and constant pounding from jumping and landing. Some skaters actually limit their number of jumps, to minimize this type of injury. However, ankle sprains are without a doubt the most common injury. But, rarely are ankles rolled when inside the skate. Advancements in ankle support have provided skaters with the support they need for larger aerial tricks, but have caused figure skaters to develop weak muscles on the outside of the ankle (Peroneus muscles), and many figure skaters roll their ankle when performing off-ice training.

The knee joint also takes quite a pounding from the constant jumping and impact of landing on the hard ice. Patellofemoral Pain Syndrome and Patellar Tendinitis (AKA “Jumper’s knee”) are common condition seen in many athletes who jump repeatedly, such as basketball players. The explosive contractions and consistent pounding can cause irritation of the kneecap and Quadriceps tendon. Unlike other sports, acute injuries such as ACL and Meniscus injuries are actually rather uncommon in figure skating.

With so much of a skater’s technique and skill rooted in practice and routine, the excessive repetition of the same motions during take off, landing, and spin direction, apply an unbalanced set of forces on the body, creating skeletal and muscular imbalances. Often times this asymmetry manifests itself with pain in the hips and pelvis, due to differences in flexibility and strength in the lower extremities. Figure skaters often experience pain in the SI Joint, where the Sacrum connects with the ileum of the pelvis. It is also common for young figure skaters to experience inflammation of the abdominal muscles where they attached to the hip bones. This condition is called iliac crest apophysitis. It is caused when young skaters, who still have open growth plates at the hips, over exert their oblique muscles, trying to produce more torque to complete more rotations during a jump.

Back injury is also extremely common amongst figure skaters. Their excessive mobility and frequent hyperextension can predispose them to conditions such as Spondylolisthesis or Spondylolysis, where the lumbar vertebrae move forward on top of each other, even causing fracture in some cases. Furthermore, muscle strains, spasms, and injury to the facet joints between each vertebrae are also very common. A skater’s style, nutritional status and muscle tone can potentially contribute to a predisposition for back injury.

I think if you were to ask an Olympic skater to count the number of times they have crashed landed on the ice, they wouldn’t be able to count them on one hand. But they might be able to count it on one wrist. Falling on an outstretch hand is the primary cause of injuries to the upper extremity in figure skaters. Although injuries to the hips, knees and ankles are much more common, every skater has most likely had atleast one wrist injury. Wrist sprains or fractures of the Radius and Scaphoid bones are common with impact in such position, and are much more common in unexpected falls.

With such a rigorous training schedule and high degree of risk, figure skaters are prone to many “sports specific injuries”, and require a multitude of treatments to stay on the ice. Copious amounts of rehabilitation and medical therapy are required to properly treat a skater’s ailments. With advancements in Orthobiologic therapy and approval by the World Anti Doping Agency, figure skaters have turned to Platelet Rich Plasma (PRP) to help speed up recovery time from injury. Canadian Figure Skating star Kaetlyn Osmond was hampered with many chronic injuries, including a chronic hamstring tear, prior to the Olympics. After undergoing a PRP injection to the hamstring, Kaetlyn was able to return to jumping and managed to gain momentum just in time for the Sochi games.

Orthobiologic treatments such as PRP are gaining much exposure for their use in professional athletes, such as Olympic figure skater Kaetlyn Osmond, and have exhibited regenerative potential and tissue healing properties in extensive clinical trials. Pioneers such as the Orthohealing Center are constantly working to progress the field of Orthobiologics. Check out the Orthohealing website for more information about Platelet Rich Plasma and Orthobiologic treatment.

Latest 5 Treatment Options - Brain Tumors

The Research and Treatment of Brain Tumor

1. Immunotherapy. Immunotherapy, also called biological response modifier (BRM) therapy, is designed to boost the body's natural defenses to fight the cancer. It uses materials either made by the body or in a laboratory to improve, target, or restore immune system function. Different methods are being studied for brain tumors, such as the use of dendritic cells or the use of vaccines aimed against a specific molecule on the surface of the tumor cells. Several methods are currently being tested in clinical trials.

2. Oncolytic virus therapy. This therapy uses a virus that infects and destroys tumor cells, sparing healthy brain cells. It is currently being researched as a treatment for brain tumors.

3. Targeted therapy. As outlined in Treatment Options, this type of treatment targets faulty genes or proteins that contribute to a tumor’s growth and development. Research continues on the use of therapies for brain tumors that target the different ways a tumor grows, how a tumor spreads, and how tumor cells die.

4. Blood-brain barrier disruption. This technique temporarily disrupts the brain’s natural protective barrier in order to allow chemotherapy to more easily enter the brain from the bloodstream.New drugs and combinations of drugs. Researchers are looking at using drugs currently used for other types of cancer as treatment for a brain tumor. In addition, combinations of drugs that target different pathways a tumor uses to grow and spread are being explored. Since tumors can develop resistance to chemotherapy, meaning the treatment stops working, another approach is to use a treatment that targets how tumor cells develop resistance.

5. Gene therapy. This type of therapy seeks to replace or repair abnormal genes that are causing or helping tumor growth